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Is R.I.C.E. the right treatment approach to Tennis Elbow?

Answer by Allen Willette:

No. Not only is R.I.C.E. (Rest, Ice, Compression, Elevation) falling out of favor for tendon problems like Tennis Elbow – it's usefulness for many other types of injury is now being questioned.

One of the problems with using the RICE protocol to treat Tennis Elbow (or Golfer's Elbow) is that the protocol is meant for Acute Injuries.

  • Tennis Elbow is not an Acute (sudden, traumatic) injury marked by inflammation and swelling, however.
  • It's a gradual, chronic tendon breakdown process marked with little or no inflammation present (usually.)

The RICE protocol is meant to be applied immediately following an Acute Injury, such as an ankle sprain where there is obvious, sudden damage and subsequent pain, redness and significant swelling (symptoms of an inflammatory process following an injury.)

Although, now even this application is coming under scrutiny.

I was surprised to recently learn that the Doctor who coined the RICE acronym for sports injury first aid has radically changed his position on icing / Cryotherapy.

Here's a quote from him on why ice delays recovery:

“Coaches have used my 'RICE' guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.”

Gabe Mirkin, MD, co author of 'The Sports Medicine Book'
Why Ice Delays Recovery

Although no sources I'm aware of recommend the 'Compression' and 'Elevation' parts of the protocol for Tennis Elbow, ice is still prescribed and casually recommended in a knee-jerk manner for "the inflammation.”

(The rest component is more complicated and nuanced, so here's something on that: Treating Tennis Elbow: Does R.I.C.E. + Rest = Rust? (with image) · TennisElbowTutr and let's just focus on the ice part here.)

A lot of the confusion lies in two related, mistaken ideas – Or outright myths:

  1. The first myth is that tendon problems like Tennis Elbow are inflammatory (Again, not so. They are degenerative in nature)

    'Overuse Tendinosis, Not Tendinitis Part 1'
    Phys Sportsmed. 2000 May;28(5):38-48.
    Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem.

  2. The second, is that inflammation must be “managed” or suppressed (Inflammation is a natural, normal part of the healing process)

As Dr. Mirkin and countless others will tell you:

“Healing requires inflammation” and, “Anything that reduces it also delays healing!”

Joshua Stone, a heavily-credentialed Athletic Trainer has an excellent series (at least 4 posts) on RICE and icing at Stone Athletic Medicine.

It's not specific to Tennis Elbow treatment but the same principles apply for the most part, including that you can't have tissue repair or remodeling without inflammation.

Here are three key points if you want to get into the science (beyond what you'll find on WebMD):

“Inflammatory cells are designed to release a hormone known as Insulin-like Growth Factor (IGF-1). IGF-1 is a primary mediator of the effects of growth hormone and a stimulator of cell growth… ice inhibits the release of IGF-1”

Ice does not facilitate proper collagen alignment. (Collagen is the protein that your tendons are mostly composed of)

Ice interrupts cellular signals and suppresses new cell development

'10 Reasons – Icing Injuries is Wrong,' Joshua Stone
10 Reasons – Icing Injuries is Wrong

Can you use ice for occasional, temporary pain relief?

Sure. It's certainly better than taking toxic anti-inflammatories – or worse, getting a Cortisone shot!

Allen Willette's answer to What are the downsides of cortisone injection for tennis elbow?

But only use it as briefly and as infrequently as possible, with the full understanding that you're only suppressing symptoms in the short term with the potential cost of delaying your healing.

And drop the outdated and misapplied practice of icing 3-4 times a day for weeks on end to "reduce" inflammation and to supposedly "help it heal" – You might inadvertently accomplish the opposite!

For more detail about Tennis Elbow and ice specifically, see my post about why you shouldn’t use ice to treat it:

Don't Use Ice to Treat Your Tennis Elbow! (Really)

Is R.I.C.E. the right treatment approach to Tennis Elbow?

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